Please enable JavaScript in your browser to complete this form.Date of Referal *Medical Assistant # *Client Name *FirstLastD.O.B. *Age *SS# *RaceGenderMaleFemaleStreet Address *City *State *Zip *Phone # *Alternate Phone #Parent/Guardian *Relationship *Parent/Guardian Street Address *Parent/Guardian City *Parent/Guardian State *Parent/Guardian Zip *Parent/Guardian Primary Phone *Parent/Guardian Alternate PhoneDSS Involved *YesNoDSS Worker NameDSS Worker Phone #DSS Worker Fax #SupervisorSupervisor Phone #Supervisor Fax # (copy)Diagnosis ICD-10Reason For Referral *Emotional/Mental IllnessEmployment InstabilityFinancial Instability/DifficultyBehavior/Conduct ProblemsLegal Issues/IncarcerationMedication Mismanagement/MonitoringPhysical/Emotional AbuseRelational ConflictsSexual AbuseSocial Interpersonal ChallengesSuicidal/HomicidalSubstance AbuseSchool Problem/SuspensionCPS InvolvedHomelessness/At Risk of HomelessnessCheck All That ApplyPRP SERVICES REQUESTED – Self Care Skills:Personal HygieneGroomingNutritionDietary PlanningFood PreparationSelf Administration of MedicationCheck All That ApplyPRP SERVICES REQUESTED – Social Skills:Community Integration ActivitiesDeveloping Natural SupportsDeveloping Linkage with and Supporting the Individual’s participation In Community ActivitiesCheck All That ApplyPRP SERVICES REQUESTED – Independent Living Skills:Skills Necessary for Housing StabilityCommunity AwarenessMobility and Transportation SkillsMoney ManagementAccessing Available Entitlements and ResourcesSupporting the Individual to Obtain and Retain EmploymentHealth Promotion and TrainingIndividual Wellness Self-Management and RecoveryTime ManagementCheck All That ApplySymptoms and Behavior/Risk BehaviorsAnxiety / PanicAttachment ProblemsDepressedFire SettingHomicidal IdeationsHopelessness / HelplessnessHyperactiveImpulsiveIrritableIsolativeLying / ManipulativeManic MoodObsession / CompulsionOppositional DefiantPhysical AggressionProperty DestructionRunning AwaySelf-Care DeficitSelf-Injurious BehaviorSeparation ProblemsSexually InappropriateSocial / WithdrawalStealingSuicidal IdeationTrauma-RelatedVerbal AggressionOtherCheck All That ApplyIs client on medication? *YesNoIf yes, please list medication dosage.Does client have a history of Psychiatric Hospitalization? *YesNoDate and TimeIs client currently receiving mental health services. *YesNoTherapist Name *FirstLastPractice Name *Practice Phone # *Therapist Credentials *Authorization *I am authorized or have been given authorization to give consent for PH-PRP to collaborate with service providers to receive and verify the information on this form for screening assessment purposes, and to determine the appropriateness of services for above referenced individual.Submit